Chemical peritonitis associated with intraperitoneal vancomycin: A case series

Peritonitis is a serious complication in peritoneal dialysis, usually secondary to an infectious cause. Chemical peritonitis is rarer. No case exclusively attributed to vancomycin has been reported in the last 20 years. Data from 4 consecutive patients diagnosed with culture -negative peritonitis following administration of intraperitoneal vancomycin between May and June 2019 were retrospectively recorded. All patients were treated with 2 grams of intraperitoneal vancomycin after a break in aseptic technique and developed a cloudy effluent. No patient was previously known to be allergic to vancomycin. All had a clear dialysate before vancomycin. All developed an elevated leukocyte count in the dialysate. All had sterile cultures. All resumed a clear effluent with less <100 cells/μL after vancomycin cessation, and in two there were no further administrations. In one, a new drug challenge led to recrudescence of abdominal pain and reappearance of a cloudy sterile effluent. In another, vancomycin from a different lot was administrated 3 days after, no symptoms developed and dialysate cell count remained normal. The pathogenic mechanisms underlying chemical peritonitis are not fully known. The clinical course is typically benign. Management seems to be limited to drug withdrawal. If unrecognized, chemical peritonitis may ultimately lead to unnecessary catheter removal.

Management of hemoperitoneum due to rupture of the ovarian cyst

Ovarian cyst is the most common female gynecological pathology and it is characteristic of reproductive age. Its rupture causes the sudden onset of pelvic-abdominal pain, often associated with physical exertion or sexual contact. The differential diagnosis is made with other causes of lower abdominal pain: ectopic pregnancy, adnexal torsion, pelvic inflammatory disease or acute appendicitis. The clinical picture may vary depending on the type of ruptured cyst. Dermoid cyst causes severe symptoms due to chemical peritonitis that occurs in response to extravasation of sebaceous contents in the peritoneal cavity. Surgical treatment is indicated for complicated forms of cystic rupture. Most cases have self-limiting, quantitatively reduced bleeding and spontaneous resorption within a few days. Patients diagnosed with ovarian cyst are recommended for regular ultrasound monitoring to prevent complications such as cystic rupture or adnexal torsion. The identification of any ovarian tumor mass in the woman at menopause requires further investigation to rule out the causes of malignancy.

Kultur Bakteri Positif pada Pasien dengan Perforasi Gaster di RSUD Dr. Moewardi Surakarta: Sebuah Studi Retrospektif

<p class="AbstractNormal"><strong>Pendahuluan: </strong>Perforasi gaster mengakibatkan kebocoran asam lambung kedalam rongga perut, sehingga berkembang menjadi peritonitis kimia. Infeksi bakteri dapat menyertai peritonitis dengan mayoritas patogen penyebab infeksi adalah <em>Enterobactericeae Sp.</em>, <em>Stretococcus Sp.</em>,<em> dan</em> <em>Bacteroides Fragilis</em>.<strong> </strong>Penelitian ini bertujuan untuk mengetahui profil penderita perforasi gaster dengan kultur bakteri positif di RSUD Dr. Moewardi.</p><p class="AbstractNormal"><strong>Metode: </strong>Pasien diobservasi secara retrospektif dari rekam medis pasien yang didiagnosis perforasi gaster dalam kurun waktu 2017 - 2018.</p><p class="AbstractNormal"><strong>Hasil: </strong>Dalam 2017-2018 ditemukan 84 pasien, 13 diantaranya hasil pemeriksaan kultur positif, onset dilakukan operasi lebih dari 12 jam pada 10 pasien (77%) wanita, 3 pasien (23%) Laki-laki. Sembilan pasien (69%) diatas umur 40 th, 4 pasien (31%) dibawah 40 th. Berdasarkan letak perforasi, 1 pasien (8%) di Antrum, 10 pasien (77%) di pylorus dan 2 pasien (15%) di curvatura mayor. Jenis bakteri yang ditemukan <em>Staphilococcus Epidermidis </em>4 pasien (30%), <em>Staphilococcus Haemoliticus</em> 5 pasien (40%) dan <em>Enterobacter chloacae </em>4 pasien (30%).</p><p class="AbstractNormal"><strong>Kesimpulan: </strong>Didapatkan 13 pasien pemeriksaan kultur positif. Tidak ditemukan jenis bakteri yang dominan.</p><p class="Keywords"> </p><div class="WordSection1"><p class="AbstractNormal"><strong>Introduction: </strong>Gastric perforation results in leakage of stomach acid into the abdominal cavity, thus developing into chemical peritonitis. Bacterial infections can accompany peritonitis with the majority of pathogens causing infection are Enterobactericeae sp., Streptococcus sp., and Bacteroides fragilis. This study aims to determine the profile of patients with gastric perforation with positive bacterial culture in Dr. Moewardi Hospital Surakarta.</p><p class="AbstractNormal"><strong>Methods: </strong>Patients were observed retrospectively from the medical records of patients diagnosed with gastric perforation in the period 2017 - 2018.</p><p class="AbstractNormal"><strong>Results: </strong>In 2017-2018 84 patients were found, 13 of them were positive culture results, the onset of surgery was more than 12 hours in 10 patients (77%) female, 3 patients (23%) male. Nine patients (69%) were over 40 years old, 4 patients (31%) were under 40 years old. Based on the perforation location, 1 patient (8%) in antrum, 10 patients (77%) in pylorus and 2 patients (15%) in curvatura major. The types of bacteria found were Staphylococcus epdermidis in 4 patients (30%), Staphylococcus haemoliticus in 5 patients (40%) and Enterobacter chloacae in 4 patients (30%).</p><p class="AbstractNormal"><strong>Conclusion: </strong>There were 13 positive culture examination patients. No dominant bacterial type was found.</p><p class="Keywords"><strong>Keywords:</strong> retrospective, gastric perforation, infection, bacterial culture</p></div><p class="Keywords"><strong><br clear="all" /></strong></p>

Meconium peritonitis in a preterm infant: a surgical emergency

Meconium peritonitis is sterile chemical peritonitis that occurs after intestinal perforation resulting in meconium leakage and subsequent inflammatory cascade within the peritoneal cavity. The clinical presentations after birth can range from completely sealed-off peritonitis without any symptoms, to severe peritonitis requiring emergency surgical intervention. We describe a case of meconium peritonitis in a premature infant following intestinal perforation. In the immediate postnatal period, the patient was intubated and a peritoneal drain was placed. Laparotomy with bowel resection was performed the following day. The postoperative course was uneventful and the patient was discharged home in good clinical condition.

Meconium Cyct in Preterm Baby

Meconium cyst in pre-term baby is rare. Meconium pseudo cyst is a complication of meconium peritonitis which is a sterile chemical peritonitis due to intrauterine bowel perforation. When the perforation in the intestine does not heal and communication with the cyst persist postnatal that can lead to cyst expansion, infection of the cyst or rupture of pseudo cyst. This is a case report of a neonate with rupture of meconium pseudo cyst causing perforation peritonitis [1]. Our case is preterm 32 weeks part of twins, cesarean section presented with huge abdominal distention diagnosed prenatal as meconium cyst.

Chemical Peritonitis Due to Spontaneous Ruptured Teratoma: A Case Report

One of the most common benign tumors in reproductive age women is mature Teratoma. We reported a 35-year-old woman who presented with abdominal pain, nausea, vomiting, and fever. The patient underwent laparotomy with the probable diagnosis of ovarian torsion. The evidence in the peritoneal cavity revealed chemical peritonitis due to the spontaneous rupture of the dermoid cyst.

Ovarian Sparing Surgery in Mature Ovarian Teratomas in Children: A 20-Year Single-Center Experience

Introduction Despite its benign nature, possible bilateral presentation, and a very good prognosis, ovarian sparing tumorectomy (OST) in mature ovarian teratoma (MOT) is not commonly performed. Unilateral oophorectomy has physiological consequences, while bilateral is devastating. The aim of this study is promotion of OST in MOT among children. Materials and Methods We reviewed 120 patients operated for MOT between August 1999 and 2019. Results Ovariectomy was performed in 15 patients (14 between 1999 and 2009 and 1 after 2010). In 105 girls, OST was possible including 32 with ovarian torsion. The approach was laparoscopy in 30 girls (11 conversions) and laparotomy in 94. Intra-abdominal spillage occurred in 30% of laparoscopic dissections. Postoperative morbidity was not associated with surgical approach (p = 0.613) or presence of adnexal torsion (p = 0,608). Follow-up was from 4 months to 9 years (median = 4 years) with access to 90% of patients. Bilateral lesions were observed in six (synchronous in five and metachronous in one) patients. Recurrence appeared in three patients operated via laparotomy and OST (after 12, 46, and 74 months). In one girl, asynchronous contralateral MOT was found 5 years after unilateral oophorectomy. Ovarian regeneration after torsion was observed in sonography in 84.4% of the patients. None of the patients experienced chemical peritonitis or malignant tumor transformation. Conclusion OST is safe and effective and should be the first-line procedure in children. Laparoscopy and laparotomy constitute a complementary approach to MOT. Ultrasound follow-up is necessary to monitor recurrence, contralateral disease, and ovarian regeneration.

P1188ICODEXTRIN-INDUCED CHEMICAL PERITONITIS IN A PATIENT WITH CARDIORENAL SYNDROME

Background and Aims The main cause of morbidity among patients who undergo peritoneal dialysis (PD) remains peritonitis. However there are rare references in published literature about the development of sterile peritonitis related to exposure to PD materials used to overcome the complications from glucose solutions.The objective of the present case report is to enhance clinical suspicion in order to avoid unnecessary antibiotic treatment or catheter removal. Case description A 56-year-old male became dialysis dependent from June 2017 due to cardiorenal syndrome type II, after multiple hospitalizations for pulmonary edema within a year. The patient was prescribed icodextrin 7,5% as a single 10-hour nocturnal dwell with dry day period in continuous ambulatory PD .At his scheduled appointment during drainage of the nighttime dialysate, slightly cloudy effluent with a lot of pale yellow substances “sesame” like, were observed without any signs of peritonitis or pathology from the Catheter exit site based on Twardowski classification.The dialysate contained 600 cells/ml. The floating yellow substances after laboratory and light microscopy examination accumulated epithilium cells with rare macrophages were found.Due to these findings,icodextrin was discontinued and empiric antibiotic therapy started including intraperitoneal administration of vancomycin and ceftazidime .After 3 days the floating substances disappeared and the number of cells in dialysate progressively decreased but not within the normal range so empirical antifungal therapy was decided. Daily repeated aerobic, anaerobic and fungal cultures of effluent and blood were negative as well the culture of exit site. ADA (adenosine deaminase test) and β-koch culture were also negative. Computed tomography scan of abdomen and colonoscopy showed no pathology.Due to fluid overload an additional long-term dwell of icodextrin solution was initiated.The re-exposure doubled the number of cells (310 cells/ml) and a second sample was sent for cytological examination which showed plenty of hyperplastic mesothelial cells in piles and isolated, abundant mature lymphocytes, few polymorphonuclear leukocytes as well as several mast cells. Based on these observations peritoneal cavity remained empty for 24 hours. Afterwards a 4-hour exchange of glucose-containing solution of 1,36%, 2,27%, 3,86% and finally of icodextrin was held once daily. The cells were 155, 120, 105 and 450/ml respectively with lymphocytes and mast cells being predominant.Based on these data, it was considered that the exposure to icodextrin produced hypersensitivity and the empiric antibiotic therapy was discontinued.The catheter was removed and sent for culturing which was negative.The biopsy of peritoneal membrane revealed mild fibrous sclerotic lesions, fibrous texture, partially collagenized membrane lacking mesothelial lining and exhibiting sparse chronic nonspecific inflammatory infiltration involving rare neutrophilic leukocytes. Plenty of small blood vessels were observed, with no immunomorphological features including IgG4 staining. These findings were attributed to chemical peritonitis from icodextrin solution ant the patient switched dialysis modality. Discussion:the use of icodextrin in peritoneal dialysis patients has numerous advantages over glucose-based dialysates including improved ultrafiltration, better fluid control and less hypertension, especially in patients with cardiorenal syndrome. In the face of evident benefits, clinicians should, however, be aware of the potential of icodextrin to induce chemical sterile peritonitis.

Chemical peritonitis resulting from spontaneous rupture of a mature ovarian cystic teratoma: a case report

Background. Mature cystic teratomas (dermoid cysts) are the most common germ cell tumours with 10–25% incidence of adult and 50% of paediatric ovarian tumours. The aetiology of dermoid cysts is still unclear, although currently the parthenogenic theory is most widely accepted. The tumour is slow-growing and in the majority of cases it is an accidental finding. Presenting symptoms are vague and nonspecific. The main complication of a dermoid cyst is cyst torsion (15%); other reported complications include malignant transformation (1–2%), infection (1%), and rupture (0.3–2%). Prolonged pressure during pregnancy, torsion with infarction, or a direct trauma are the main risk factors for a spontaneous dermoid rupture that can lead to acute or chronic peritonitis. The diagnosis of mature cystic teratoma is often made in retrospect after surgical resection of an ovarian cyst, because such imaging modalities as ultrasound, computer tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign and malignant pathology. Materials and methods. We present a report of a clinical case of a 35-years-old female, who was referred to the hospital due to abdominal pain spreading to her feet for three successive days. She had a history of a normal vaginal delivery one month before. Abdominal examination revealed mild tenderness in the lower abdomen; no obvious muscle rigidity was noted. Transvaginal ultrasound showed a multiloculated cystic mass measuring 16 × 10 cm in the pelvis. In the absence of urgency, planned surgical treatment was recommended. The next day the patient was referred to the hospital again, with a complaint of stronger abdominal pain (7/10), nausea, and vomiting. This time abdominal examination revealed symptoms of acute peritonitis. The ultrasound scan differed from the previous one. This time, the transvaginal ultrasound scan revealed abnormally changed ovaries bilaterally. There was a large amount of free fluid in the abdominal cavity. The patient was operated on – left laparoscopic cystectomy and right adnexectomy were performed. Postoperative antibacterial treatment, infusion of fluids, painkillers, prophylaxis of the thromboembolism were administered. The patient was discharged from the hospital on the seventh postoperative day and was sent for outpatient observation. Results and conclusions. Ultrasound is the imaging modality of choice for a dermoid cyst because it is safe, non-invasive, and quick to perform. Leakage or spillage of dermoid cyst contents can cause chemical peritonitis, which is an aseptic inflammatory peritoneal reaction. Once a rupture of an ovarian cystic teratoma is diagnosed, immediate surgical intervention with prompt removal of the spontaneously ruptured ovarian cyst and thorough peritoneal lavage are required.